The U.S. Department of Defense (DoD) is an established leader in promoting sustainability in the built environment. Government agencies have promoted green building practices for many years. Since 2000, when the U.S. Green Building Council (USGBC) published the first edition of Leadership in Energy and Environmental Design (LEED) for new construction, 28% of the more than 35,000 total building projects participating in the LEED certification and rating process are federal, state, and local government owned or occupied. The federal government is the largest single owner of LEED certified buildings. Even among federal agencies the Department of Defense stands out as a leader; as of January 2010, 189 federal projects had received certification, and 49 of those projects, roughly 25%, were for the Department of Defense (DoD), more than any other federal government agency (National Renewable Laboratory for the U.S. Department of Energy Federal Energy Management Program, 2010). Currently, the number of registered and certified federal projects has dramatically increased to 369 and another 3,665 federal projects are pursuing certification (U.S. Green Building Council, 2011).

More than LEED

Executive Order 13423, Strengthening Federal Environmental, Energy, and Transportation Management, signed in 2007, requires Federal agencies have “a plan to implement sustainable design, construction, and operation and maintenance” (U.S. Department of Energy & Federal Energy Management Program, 2010). The Executive Order also established an Interagency Sustainability Working Group that developed High Performance and Sustainable Building (HPSB) Guiding Principles that apply to all new federal construction with the goal of reducing energy consumption and environmental impact of all federal buildings, including healthcare facilities. The Guiding Principles apply sustainable building design, construction, and maintenance to the existing federal building stock, new construction, and major renovations through five principles.

The five principles include employ integrated design principles, optimize energy performance, protect and conserve water, enhance indoor environmental quality, and reduce environmental impact of materials. Implementation of these principles should help the federal government meet their goals of improving water conservation and energy efficiency, reducing ownership costs, promoting sustainable environmental stewardship, and providing healthy, safe, and productive built environments.

In addition to LEED and the HPSB Guiding Principles, the DoD must construct facilities to comply with many other federal ordinances, mandates and policies including Executive Order 13423, Executive Order 13514, Federal Leadership in Environmental, Energy, and Economic Performance, EPAct 2005, EISA 2007. However, overlap occurs between the federal policies, ordinances, and mandates that promote sustainability and the potential LEED credits to be achieved. Although each of the Services within the DoD has its own requirement that facilities be built to LEED Silver standards, simply achieving LEED Silver does not guarantee compliance with all required sustainability regulations. Conversely, complying with all the federal sustainability regulations may or may not result in a LEED Silver certification. The combination of federal mandates, executive orders, and policies as well the Services’ LEED requirements ensure the highest level of sustainability.

The multiple sources of regulation prove to be even more challenging for the Military Health System (MHS), the agency within the DoD responsible for providing healthcare to military personnel. The synergies between delivering care and environmental sustainability has allowed the MHS to become a leader in the design and construction of sustainable, world class healthcare facilities such as the Community Hospital at Ft. Belvoir and the Replacement Hospital at Ft. Riley.

Sustainable Healthcare Guidance

Until recently the Green Guide for Health Care (GGHC) was the only green building standard that primarily focused on the specific and unique components of design, construction, operations and maintenance of healthcare facilities. Released in 2003, the GGHC intends to provide “healthcare specific and health focused tools, technical guidance, and educational resources to a learning community” for the creation and implementation of “high performance healing environments” (Green Guide for Health Care, 2010). The GGHC utilizes the language and structure found in LEED credits for New Construction and Existing Buildings (U.S. Green Building Council, 2011). As of February 2011, more than 280 projects were registered with the self-certifying, voluntary program however; none of these were federal healthcare projects.

The USGBC released a standard specifically for healthcare, LEED 2009 for Healthcare, in late 2010 (U.S. Green Building Council, 2010). This standard was built with the help of many of the same people that developed GGHC and based on the pilot program experiences of the GGHC. The newly released standard includes various modifications to the LEED 2009 standard related to prerequisites and credit opportunities to make it more applicable to healthcare settings. Additional emphasis is placed on integrative project planning and a design process that engages a multitude of disciplines in keeping human health as a ‘fundamental evaluative criterion for building design, construction and operational strategies.’ (ID Prereq 1 from LEED 2009 for Healthcare 2010).

World Class

Beyond federal mandates that require DoD projects to meet sustainability standards, the MHS is tasked with building ‘world class’ facilities that support the best possible care for our services men and women. In 2008 the Assistant Secretary of Defense tasked a subcommittee of the Defense Health Board with reviewing the health facility projects underway in the National Capital Region to evaluate whether or not these projects would help the DoD achieve their goals of providing world class care. Part of the report that this group released included a thoughtful and thorough definition of world class for a healthcare facility. . In addition to many other criteria specific to design and operations of a healthcare facility, The Defense Health Board report, “Achieving World Class,” states that for a medical facility to be considered World Class it must “demonstrate environmental responsibility and sustainability in the facility design, construction and operation by, but not limited to: having achieved LEED certification [and] embracing the recommendations contained in the latest edition of the Green Guide for Health Care (GGHC)(Green Guide for Health Care, 2010). Military Health System projects that have gone out for bid since this report was released have added world-class criteria to their requests for proposals, in addition to sustainability as a core principle, raising the bar even higher.

Increased Scrutiny on Building Impacts

Signed by President Obama in October 2009, Executive Order 13514 on Federal Leadership in Environmental, Energy and Economic Performance required all Federal agencies to produce sustainability plans that would set concrete targets for energy, waste and water conservation.

The DoD’s first Strategic Sustainability Performance Plan was released on September 8, 2010 and included measurable targets for the reduction of fossil fuels, solid waste, and greenhouse gas emissions associated with facilities in addition to operations. Performance toward these targets will have to be reported on a semi-annual basis by all DoD departments, agencies and field activities (Department of Defense, 2010). Achieving these aggressive goals will require a commitment to sustainable design, construction and operation of all military facilities. While healthcare facilities are not singled out, they are covered by these commitments and will be an important part of the DoD achieving their goals. This report solidifies and makes clear the commitment to sustainability that was already apparent within the DoD, accelerating the actions that they were likely to take. Combined with the emphasis on world-class facilities it is clear that the MHS is motivated and committed to creating exemplary sustainable healthcare facilities.

Even with the advancements of the LEED certification program, healthcare projects have generally been slower than other market sectors to adopt sustainable building practices. Industry professionals have traditionally placed primary focus on the safety and well being of patients and felt that attention to environmental issues would compromise their efforts. Others have resisted applying green building strategies to healthcare because the existing guidance and tools are not tailored to unique characteristics of healthcare facilities. Additional explanations for the slower pace of sustainability in healthcare include too many regulatory requirements and a risk adverse culture as well as additional cost. However, keeping patients safe and doing no harm is consistent with sustainability. MHS hospitals have shown a commitment to sustainability and have provided performance standards for other facilities in the industry to model. The following table shows the remarkable achievements are anticipated in two MHS projects currently being constructed.

While the DoD is a leader in creating sustainable buildings it is faced with a number of challenges. Sustainability is but one goal that the DoD must balance against specific issues in MHS projects: meeting anti-terrorism and force protection requirements; covering the potential of additional upfront costs for sustainable design features; and awareness of the multitude of federal sustainability requirements. For example, anti-terrorism standards require building separation as well as separate constructs for power and fuel supply, but LEED encourages dense development for sustainable sites and minimal building footprint to prevent habitat disturbance.

Furthermore, industry professionals are still learning the process and implementation of sustainable design. Healthcare design professionals must balance the intricacies of designing a healing environment that embraces evidence-based design principles and maximizes environmental conservation and preservation. Architects and engineers are not always aware of the specific requirements found within the various federal mandates due to the large amount of guidance coming from different sources,

In spite of the challenges and complexity facing the design and construction of sustainable healthcare facilities, the MHS is in the process of constructing the following hospitals targeting high levels of LEED certification.

Target LEED Certification Level of MHS Hospitals

Walter Reed National Military Medical Center

Gold

Ft. Riley Replacement Hospital

Silver

Community Hospital at Ft. Belvoir

Silver

Community Hospital Add at Ft. Stewart

Gold

Martin Army Community Hospital at Ft. Benning

Gold

Ft. Hood Replacement Hospital

Gold

Camp Pendleton Navy Hospital

Gold

The Department of Defense has been a leader in promoting sustainability in its facilities and is poised to make an even bigger impact with commitments to increasing the energy efficiency of its building portfolio and shifting more of its energy consumption to renewable sources. With the large number of healthcare facilities being planned and built in the next few years, the Military Health System (MHS) has an opportunity to deliver high performance sustainable buildings that support world-class care. We should look to the hospitals that they are building now was models for sustainable hospital design.

About the Authors

Jennifer DuBose is a Research Associate with the College of Architecture at the
Georgia Institute of Technology where she is responsible for project development and management.

Ms. DuBose is a LEED accredited professional with a background in sustainable facilities and organizational sustainability. She has worked with government and private sector clients to help them develop

policies and strategies for greening their facilities and operations. Ms. DuBose has a master’s

degree in public policy from Georgia Tech with a focus on sustainable development. After

completing her undergraduate degree in Philosophy at Oglethorpe University she served as a

Peace Corps Volunteer in the Democratic Republic of Congo. She may be reached at

Joshua Crews is a Graduate Research Assistant at the Georgia Institute of Technology in Atlanta, Georgia. Josh graduated from the University of Florida in 2007 with a Bachelor of Design in Architecture and pursued his career in healthcare design with Gresham, Smith and Partners until beginning his graduate studies at Georgia Tech. He is currently conducting research on sustainability in the Military Health System, flexibility in healthcare architecture, and the utilization of Active Design Guidelines in multi-family affordable housing projects. Josh is part of the Healthy Environments Research Group within the Health Systems Institute and is pursuing the Master of Architecture professional degree in the College of Architecture. You can contact Josh at crewsj@gatech.edu.